What Will a Cat’s Face Look Like in Pain?

Cheek bunching on the left side (right cheek) of this cat. Eyes not wide open, ears down, not paying attention to camera.

How to Read Pain in Mammal’s Faces

Research out of Dr. Mogill’s laboratory at McGill University in Canada, published in Nature Methods, (June 2010) studied mouse faces to see what the signs of pain were. The researchers injected a chemical into the mice to be certain they were in pain and adjusted cameras to capture their tiny little faces to see what changes they could see. We will discuss the features of a mouse in pain and then we will see how a cat in pain shows the same signs of pain in the face.

A mouse who is experiencing pain will tighten and hold muscles in and around his or her face in certain distinctive patterns.

Cheek Bunching

Mice will bunch up their cheeks into tight little knots of pain. Their cheek fur sticks straight up underneath their eyes and does not lay smooth and flat on their faces. Cheek bunching indicates pain.

Eye Squinting

They squint their eyes. The mice look like they are looking out into bright sun, except they really don’t care to look at anything. They are not focussed outward, and their eyelids are almost shut. Combined with cheek bunching, eye squinting is a sure sign of pain.

Nose Crinkling

They crinkle their nose up, with tiny mouse wrinkles on either side of the nose. This is akin to the cheek bunching, because some of the same muscles are involved. The result is a nose crinkling, cheek bunching, eye slitting mouse in pain. Obviously.

Whisker Lowering

The mice lowered their whiskers and plastered them closer to their faces. They were not interacting with the environment.

Ear Lowering

Finally, they lower their ears. They scrunch their ears out flat like an airplane wing, or sometimes, even pull them down and back on the sides of their head. Surely, they are experiencing severe pain.

A truly fascinating observation by a pediatric oncologist led to the application of the face pain signals in mice to help children who cannot yet talk.

How Can You Tell a Child is in Pain?

Clinicians working with babies and very young children have a difficult time judging whether or not the child is in pain. If a child undergoing open heart surgery or chemotherapy, or other potentially painful experiences cannot speak, can you tell if they are in pain?

Signs of Pain in Pre-Verbal Children

Repetitive Movements

The clinicians noted that many of these pre-verbal children would perform repetitive behaviors like toe tapping and punching their bed sheets in a rhythmic pattern. When the children were administered painkillers, the repetitive movements stopped. The doctors realized the children had experienced untreated pain!

Facial Signals: Cheek Bunching, Eye Squinting, Nose Crinkling

When the mouse research came out, the pediatric clinicians looked at the faces of the children with renewed vision. They saw cheek bunching, eye suiting, and a little bit of nose crinkling. The ears gave no clues; humans do not have the agile ear muscles of a mouse or a cat. We also, obviously, do not carry whiskers! For the parts of the face with identical muscling, the behavior was identical. Children and mice show pain in their faces in the same patterns!

Cats in Pain Hold Their Face Muscles Like Mice and Children in Pain

She looked at me, but not really! Cheeks bunched, nose crinkled (not relaxed), ears not up & forward, eye openings smaller than they should be in an exciting animal hospital. Her response is totally inappropriate for the environment.

Your Truli read this research and then started looking at cats’ faces in a new light. Most people that grew up with cats, or have worked with tens or hundreds of cats, know instinctively when a cat is exhibiting pain. But how can you teach a pet parent how to judge whether or not their cat is in pain, without the personal relationship of guilt and clouded emotions getting in the way of accurate assessment of pain? And how can you teach new nurses, new doctors, and other healthcare workers? The more reliable and systematic the pain assessment, the more certain we can be that painkillers are needed.

Why not just give painkillers anyway, just in case?

Variable glucuronidation speed in different cats

Cats are sensitive to drugs. Non-steroidal anti-inflammatory painkillers (NSaids) are not processed (the process is called glucuronidation) in a cat’s liver reliably. The one NSaid US FDA-approved to treat postoperative pain in cats is only approved for one injection, with no repeated doses. Why? We know that the pain might last for 1-2 weeks, especially with orthopedic surgery?

Don’t Poison the Kitties With Painkillers!

The reason why is the variable rate at which the drug is processed in the cats’ livers. In the research trials, some cats processed half of the drug (the “half-life of the drug) in 24 hours, while other cats took one whole week to process half of the drug!!!! Repeated doses cannot be predicted when each cat should get the medicine. If your cat is a one day cat, then he needs more medicine the next day. If he is a one week cat, giving the medicine every day will give him seven times the therapeutic dose and poison him! If we have a reliable way to decide if a cat is in pain in the first place, we can decide whether to risk the medication for the comfort of the cat.

Only Risk Stressing a Cat When It Is Necessary

Cats also notoriously reject handling and medication administration. Sometimes the stress of administering the medication can make a cat hide, not eat, and become sicker. You want to be certain the stress is worth it!

Cheek area bunched and small, eyes lowered, eye openings small, ears pulled down. It's subtle but the total of the evidence=pain.

Facial Signs of Pain in Cats

Cheek bunching A cat will sit in a corner, withdrawn or even turned away. The cheeks will be bunched up under the eyes with the fur sticking up toward the eyes.

Eye Squinting The cat’s eyes are slitted almost shut, or even completely shut. Even if you talk to the cat, or touch the cat, the cat will barely open the eyes. Really, he or she is focussed on the internal pain and not very focussed on the external world. This cat in the picture is behaving completely inappropriately for a busy, noisy hospital environment. Her eyes should be wide open, ears swiveling, head and ears up. Instead, she is showing pain in her face.

Nose Crinkling Cat noses are tiny, bit f you look closely, you will see the cheeks bunched and the expression continues across the bridge of the nose. The crinkle cannot really be seen on this photo resolution. If you know cats, you can focus on her face. Do you see the relaxed anticipation, like a cat shows just before their dinner plate is set before them? Not at all!

Whisker Lowering The cat’s whiskers are not out to the sides quivering and seeking clues from the environment. They are drooping low by the face.

Ear Lowering The cat’s ears in the pictures are held out flat to the sides of her head. A normal, alert, happy cat puts their ears up, swivels the ear pines (flaps) to listen to the environment. A cat in pain is not thinking about protecting herself from the environment; she is just trying to withstand the pain. Nothing else matters to her!

Doc Truli administered painkillers just after the pictures. Rest assured, this story took far longer to write than it took to give this kitty effective opioid painkillers. She was in pain because of pancreatitis. After several days in the hospital in intensive care with intravenous fluids and special feedings, she made a full recovery.

These pictures also demonstrate a different kind of pain signals than we saw in the cat with her back hunched and her nose on the floor. Be careful in your pain interpretation. The facial signals show us pain. Lack f the signals means we must look at the whole body to be sure if the kitty is in pain or not.

References

Nature News article, with mouse face pictures, based on the Nature Methods original article (you’d have to pay for the original scientific article, if you wish to review it!)

There are huge ethics discussions online regarding this study. See IACUC.org to read about how studies are approved by researchers, community lay-people, and non-scientists at a university before the animals are ever involved.

Dear Doctor, Perhaps you have some suggestions for me and my cat. Two years ago, when he was 14 years old, I took him in to get his teeth cleaned, The vet called me during the procedure to tell me he had a pocket behind his upper left canine tooth, she suggested that they remove the tooth. I approved and have regretted it since. He was an outgoing cat, curious, always exploring and happy. He is now sad. He sleeps, is seldom interested in much, seldom participates in play. He really loves to have his jaws and cheeks scratched and brushed; really, really gets into it. He’s licked the fur off both his front wrists up to his elbows and has started on his rear legs. I thought for a while his constant eye rubbing was maybe allergies. He’s been on antihistamines, they help some and make him sleep. The vet has had him on antibiotic eye drops. He still rubs his eyes. Now how’s got scratches on his eyes. She has him on other eye antihistamines and a gel-like lubricant. I took him to another vet 3 days ago, she drew blood and spun it into serum for me to drop into his eyes. She also has him on a painkiller. He sleeps but when he’s awake he’s a bit more perky. His tummy is upset. Now I have started to wonder if he’s been in pain all this time. I’ve suspected that something happened during the surgery as he was extremely clingy and afraid of everything for several weeks after the tooth was removed. What do I do next? I have been so worried about him, I have run out of ideas how to help him. Nancy

It may be time to try integrative medicine. That means keep your veterinarian and add a Traditional Chinese Medicine-trained veterinarian. You can look for one near you at TCVM.com under the “resources” tab. Good luck,
Dr Truli

This is a great article. I have been trying to assess whether my cat is in pain from her low grade hepatic lymphoma. About 4 years ago I took her to have her teeth cleaned and found out she had ALT values of 700+. She didn’t get her teeth cleaned. Since that time she has had an ultrasound, liver biopsy, liver aspirate, two kind of chemo and radiation treatment (but no teeth cleaning)! All of which just made a seemingly well cat feel unwell…until last week. She stopped eating. I am now trying to figure out if her not eating is actually from periodontal disease and not from her liver cancer. I wish she could just tell me! She is now on an appetite stimulant and an oral pain medication. She has started eating, but only soft food. This is unusual for her as she usually prefers dry food (strange cat, I know). Last night she was running around chasing her tail. I am leaning toward the fact that it could actually be her teeth bothering her, which sort of blows my mind. Her liver alt is still really high, but I don’t **think** I see signs of abdominal pain – is liver cancer even painful? She does like to sit on all four paws and look out the window, but I don’t think she is more bunched up than usual. She still plays quite a bit. I assume if she was really in pain from the cancer, she wouldn’t do that. It seems like such a ridiculous choice to be going back and forth between putting her to sleep and cleaning her teeth – any thoughts for me?

Oh, wow! Good question! Basically, when your cat has been diagnosed with a “terminal” disease, and then needs extensive, “other” work done, will putting her through the dental procedure improve her life? Bloodwork will help tell if her liver is functioning okay, or if a common problem like kidney disease has set in. I can tell you, most cats feel 1000% better after a deep cleaning of their teeth.

It doesn’t sound like she wants to be put to sleep from your description. If you have the money, get her teeth cleaned.

If it is a financial strain, then be honest with yourself. I find many people try to turn a money question into a philosophical, ethical reason to let their cat go. They seem to feel guilty that they cannot afford $250-$1000 for possibly complex cat mouth surgery, so they come to me looking for justification, or leaning their story toward “she’s suffering” to feel better about not doing the tooth care. Or sadder still, people make up rules to justify their needs. Rules like, “she’s old anyway.” “Don’t you think we’ve put her through enough?” and “She’s only gonna live another 6-12 months anyway.” These statements seem arbitrary and human-constructed. I believe, if you can’t afford the care, then be honest and just say, “I can’t afford it.” Just don;t pretend your cat doesn’t want to live as long and happy a life as we humans can provide.

I’d say, if your kitty passes a pre-op physical and bloodwork and screening EKG & your vet agrees, then taking care of the teeth sounds like the logical, humane, fair thing to do.

Thanks for your thoughts. Her alt is around 900, so oral surgery is a bit risky. I did take her for a dental consult, where it was determined that, although her teeth need a good cleaning, she didn’t have dental disease that would cause her to not eat. I am going to try taking her off of the appetite stimulant and keep her on the oral pain meds to see if she continues to eat. If that works, I will have her teeth cleaned. It really isn’t about finances with me – obviously I have put her through two kinds of chemo and radiation therapy. I really just want to do whatever is best for her.

Dear Sylvie,
75% of my dental patients have significant periodontal disease evident on oral X-Rays that we could not see on the physical exam, even when the cat was under anesthesia. Be certain your vet regularly performs dental x-rays before you whole-heartedly accept advice that the teeth don;t look bad enough to stop her eating. If they do, then that’s probably a good educated guess. If they do not, then seek a vet who does. A dental specialist may lean too heavily toward caring for the teeth no matter what, so a good general practitioner who loves dentistry would be a good niche for you.

Just a thought: We regularly anesthetize cats with ALT higher than that because they need anesthesia for the liver biopsy surgery in order to diagnose the problem. It takes precautions ad extra care, but is something that is certainly done.

I guess how I feel about cats and dental work when they are sick and not eating chronically is this: if you are facing putting a cat down, why not try to cure her first?

Good Luck! It’s such a tough decision, trying to do right by your cat; it’s a huge responsibility and a privilege.

Ooh, I’m so glad to know that pain management is becoming more of a focus in veterinary medicine. That had been my impression, just in terms of hearing more from vets now than I used to about pain management. For example, when Jersey was dying, they refused to give me strong pain meds to give her at home, and I was afraid that would happen with Gadget, but they were much more interested in his pain management than they had been with Jersey.

It’s similar with humans. There are standards that all hospitals are supposed to ask patients about their pain and treat pain, and yet doctors are getting arrested for being drug dealers if they prescribe pain meds. It’s very hard.

I just want to make one point, which I’m sure you are painfully aware of, already, being a vet, which is that a lot of people can’t afford to save up or to pay monthly health care premiums.

I am privileged to be able to pay $25/month on vet insurance. Many people in my life who love their dogs and cats very much are barely scraping by, not having enough to eat, or choosing between food and healthcare or rent or mortgage. Of course, most of my friends are disabled, which is the poorest group in the US. But, it is sadly more and more common among both disabled people and the working and/or nondisabled poor.

I do have friends who have sacrificed their own basic needs for care for their animals, but it should not have to be that way. That’s not the fault of veterinarians, it’s the fault of our fellow citizens and government, who don’t value the lives and welfare of people who don’t have money.

This is a really useful article, Doc Truli. Thank you! (Although I feel sorry for the mice; I used to have pet mice.)

I have passed it along to the cat people in my life.

I have had the experience of knowing my dog was in pain, but not having the vet believe me. They asked if she was still eating, and I said yes, and that was it for them. But, this dog only stopped eating when she was on death’s door. She LOVED food. Also, bouviers are notoriously stoic, and she was the most stoic of the lot I’ve had. There were really obvious indicators to me, the biggest one being that she was hiding out in the bathroom, but the vet dismissed this, and since it was an ER, I had no other options. (Vet emergencies always occur at night or on the weekend.)

Do these facial expressions cross over to dogs, too? Or can you write a post about how to tell if your dog is in pain?

It hasn’t happened again, but it was disastrous at the time (she lost an eye as a result), so I always worry I’ll be in a situation where I can’t “talk Veterinarianese” and be unable to convince a vet that something is actually wrong.

It’s so important to have a regular vet who trusts you and believes in-same goes for physicians. I had a client take her Yorkie to 4 vets on vacation because the dog was walking on her front paws and holding her hind paws up in the air and frantically licking her front paws after receiving a spot-on flea treatment! 1) None of them called me to get the dog’s history 2) None of them believed her for a second 3) None of them called the flea med company to report it or ask about it 4) All of them said he knees hurt from luxating patellas (that she had her whole life and never bothered her BTW. ) When she got back home, we called the flea med company and found out it made perfect sense to them! Poor dog and poor woman to be ignored like that is so frustrating! (especially when you need help for your dog.)

In the ER, I had to quickly assess whether or not I thought someone was a good observer and understood their pet. Honestly, I hate to judge people, so I always err on the side of believing someone, rather than dismissing their concerns. I say, “I respect mother’s (or father’s) intuition.” We’re taught in vet 101 to treat the pet parent’s primary concern as our #1 concern.
Unfortunately, most ER vets don’t work on teeth, or they would see all the dogs in pain that eat! (BTW-when I was an ER vet- I treated 2x the disease on my shifts as the other two vets. Same hours worked, same odds of seeing patients. I took that respect for the clients intelligence and applied it to the ER. I found many more problems than they did!)

When I hear complaints about someone’s previous vet, it’s 95% of the time, something they did not check for, something they did not take care of. So I check. That said, it’s hard to tune out the constant stream of comments from the very same concerned pet parents that sound like they want less intervention! They say, “Take it easy on me, doc.” “I’m out of work.” “I’m on a fixed income” “I’m on disability” “Keep it under $100.” “I didn’t bring any money.” “I just spent $300 here last week.” “Do the best you can with the bill,doc.” The list goes on and on… Now, a veterinarian could easily assume these people just want a few tests. Give it the ol’ college try. We vets hear these comments all day long! Almost every person leads with a money comment. It’s exhausting and a little depressing.

If you lave a stressed-out life, especially because of money, don’t you rely on your pet to live and be happy even more than ever? I have to stay focussed on the pets and their needs and figure out their symptoms, their physical exam, their possible diagnosis (for drinking too much water, there are 41 “differentials”!), and the tests that can find the most common ones the most directly. I can’t tach someone medicine in order to explain why $225 worth of the “minimum database” of a CBC/Chem/Lytes/UA is a better deal and better for their pet than: “I think it’s diabetes, Doc. I just want a Blood Glucose (for $25. Do that guessing game and you’ve used up the money on only 10 ideas, instead of 41! Every day, all day, this is a constant pressure to divine what could be wrong without spending a lot and without missing the diagnosis on the first tests. It really is guessing and playing the odds. So frustrating and stressful for me because I care tremendously if the pet suffers through a delay in the diagnosis.

Sharon- I am not sure if these expressions cross over to dogs. Most of them have longer noses than cats and mice and people, so I have a hard time seeing the cheek bunching-nose scrunching. It’s funny- people cannot tell when their cat or mouse is in pain, but those pets seem to have the best, most obvious body language. I’ve been watching all the dogs I treat and trying to capture representative pictures. So far, not very productive. I’m working on it, though.

Huh. I can see how that would be extremely difficult, trying to balance those two conflicting needs.

I sometimes ask about cost just to know ahead of time, but I also ask what the test is for and what the differential diagnoses are. I can’t think of a time I made a veterinary decision based solely on cost. (The only reason I usually decline a procedure is if I don’t think it’s in the best interests of my animal, e.g., when Gadget was dying, after a certain point, I felt his quality of life would be better not to go to the vet on a hail Mary treatment. And I decline most vaccines because I think they pose an unnecessary risk.)

I have been very fortunate to be able to afford extreme measures of veterinary care. And now, I am fortunate enough to be able to have health insurance for Barnum so that when (notice I do not say “if”!) he ends up with a humongous medical bill at some point, we will be covered. Wish I knew about that with Gadget before he got cancer. But, live and learn.

I was not meaning for my comment to be an indictment of you or veterinarians in general. I just wanted to know if there was some sort of “factual” data I could provide that my dog is in pain if this ever happens again. Something where I could say, “I know he is eating, but if you observe blah blah blah, you will see blah blah blah….” You know? Something “empirical.”

What happened with Jersey is that I suspected glaucoma, and told them I did, and asked for them to test her pressures, and they told me they were normal. What I didn’t find out till later, when I requested her records, was that the pressure in her right eye was 24, while it was 15 in the left. They considered 25 and up to be glaucoma, so they said it was normal. I didn’t know enough at the time to ask for the *numbers.* This was not a case of me saying, “Do as few tests as possible because I don’t want to pay.” Quite the contrary!

And, it was pretty much a slam dunk: red, slightly bulging eye, much higher pressure than in the normal one, history of problems in that eye, and owner saying dog is in pain. Later, because her breeder wanted them, I requested the medical records, and the vet also falsified the records of previous visits about that eye, saying she had warned me about things that she never had, changing diagnoses, etc. Presumably to prevent being sued? Overall, not a shining example of the profession. She moved away soon after.

I have been in the position plenty of times of MDs not believing me, and I have had to shop for vets and for my own doctors who trust me as the best authority on what I’m feeling or what my animals are feeling. But yes, if you have an emergency or you’re on vacation, you can’t rely on that existing trust and relationship. Since I have moved away from Gadget’s vet, I have not yet found a vet who seems to really trust my observations and knowledge the way that his vet did. So far, that hasn’t been a problem because Barnum’s been pretty healthy.

If the pressures are different in the eyes, that is a sure sign there is a problem, even if you hadn’t said a word about pain. It sounds like that veterinarian just wasn’t very competent. I’ve seen vets write stuff in records at the time of the visit that did not jive with the visit as I saw it. Especially things about what tests were offered and what was declined or accepted by the pet parent. I wonder if those doctors actually know they did not communicate at all with the pet parent?! It should be industry standard to videotape consultations for training purposes and let the veterinarians see what they do – their body language, tone, the actual words, whether or not they paused and asked for the client’s comprehension. I think many doctors actually think they did a good job!

The International Veterinary Academy of Pain Management is a fairly new organization created to focus on these issues. Veterinary technician training teaches technicians to look for increases in breathing rate, heart rate, decreases in activity, withdrawal, and not eating as signs a hospitalized pet needs better pain management. A change in behavior, whether it be extra solicitous, or withdrawn, can be a sign of pain. A red eye is assumed to be a painful eye. Period. I doubt, short of standing on your head and screaming, that you could have presented Jersey’s case any clearer than you did!